Face Sheet, Patient Assessment & Reassessment, History, Physical Examination, Admission/Discharge Record
Face Sheet, Patient Assessment & Reassessment, History, Physical Examination, Admission/Discharge Record
Face Sheet, Patient Assessment & Reassessment, History, Physical Examination, Admission/Discharge Record
Clinical, Demographic, and 2. The face sheet contains three types of information. Name
Financial them.
Patient Name, Address, 3. Identify 4 common data elements collected on the face sheet.
Phone Number, etc.
Insurance Company Name,
Policy Number, etc.
Provisional Diagnosis 5. The physician uses the above to establish the _____
diagnosis.
Review of Systems 6. The physician's assessment of all body systems is called the:
General (includes vital signs) 8. List three contents of a physical exam report.
HEENT, Chest, etc., Lab Data,
Plan for Admission,
Impression, etc.
Interval 10. When a patient is readmitted within 30 days for the same or a
related problem, which type of physical examination can be
written?
Standing Orders 14. Name the type of orders physicians utilize for routine patient
care.
Discharge Order 15. Which order is written to release the patient from the facility?
Against Medical Advice 16. The patient who leaves the facility against express physician
(AMA) orders leaves:
Telephone (Phone) 17. Physicians are required to sign verbal orders within 24 hours
after they have been recorded in the patient's record. What
other types of orders must be signed within 24 hours of being
recorded?
Discharge Note 20. Physician progress notes should include an admission note,
follow-up progress notes and:
Admission 21. The admission note summarizes the general condition of the
patient at the time of:
TRUE 23. If the patient dies while in the hospital, the physician must still
document a final progress note. TRUE or FALSE.
Consultation Reports
Opinion 24. The consultation report documents services rendered by a
physician whose ____ is requested.
(1) Patient whose diagnosis 26. Provide two examples of a patient who would need to have a
is unclear. (2) Patient who consultation ordered.
needs medical clearance for
surgery, etc.
Documentation that record 27. Name four of the content items that the consultation report
was reviewed, physical should contain.
examination of patient,
opinion, and
recommendations
Laboratory and Radiology Reports, and Nursing Documentation
Laboratory Report 28. Which report involves the examination of materials, fluid and
tissues obtained from patients to aid in diagnosis and
treatment?
Nuclear Medicine Imaging 29. Which report describes diagnostic studies and therapeutic
Report procedures performed using radiopharmaceutical agents?
Radiographic (X-ray) Report 30. Which report documents the interpretation of fluoroscopic
diagnostic services.
Radiologist 33. Radiologic reports are signed by the and filed in the
24 Hours patient's record within:
Technologist 36. The professionals responsible for signing the laboratory report
include the bacteriologist or _____ who performed the test.
Nurses Notes 37. Which report "describes nursing observations of the patient,
care and treatment given, and the patient's response to
treatment"?
Assessment/evaluation, 38. State three of the six elements required in the nursing process
nursing diagnosis, nursing of documenting patient care.
care provided, discharge
preparations, nursing
interventions
Graphic Sheet 39. Which provides for the nursing documentation of vital signs?
Progress Notes 43. In which report would the dietitian document information
pertaining to a patient's dietary needs?
TRUE 44. The JCAHO requires diet orders to be recorded in the patient's
record prior to serving the diet to the patient. TRUE or FALSE.
Liability 46. If the patient is not required to sign a consent form prior to
treatment, this may result in _____ on the part of the facility.
Informed Consent 47. The patient or representative should indicate in writing that
(s)he has been informed of the nature of the treatment, risks,
complications, alternate treatments and consequences of
treatment. This is called:
Progress Note 51. When there is a transcription delay, the Joint Commission
requires the surgeon to document an operative:
Condition of patient, unusual 52. List 3 surgical items documented on the operating room report.
events, operative findings,
specimens removed,
procedure performed,
preop/postop dx
Progress Notes 56. In addition, the appraisal of any changes in the patient's
condition would be documented in:
Unusual events, anesthesia 57. List 3 items documented on the anesthesia record.
techniques used, anesthetic
agents administration, other
drugs administered, IV fluids,
blood/blood components
administered
Surgeon 58. Which physician documents the order releasing a patient from
the recovery room?
Complications (if any), 59. List 3 items documented in the postanesthesia note.
abnormalities (if any), date,
time, swallowing reflex,
cyanosis (if any), patient's
condition
Administration 61. The transfusion record contains patient ID, blood group/Rh of
patient/donor, crossmatching, donor's ID #, and the record of
of the transfusion.
IPPB, etc. 66. List one example of a respiratory therapy that would be
administered to the patient.
Requests for information 69. The discharge summary contains information for continuity of
(e.g., from other hospitals or care, to facilitate medical staff committee review, and to
an insurance company respond to:
Reason for hospitalization 71. The discharge summary includes a brief clinical statement of
the chief complaint and history of present illness. This is called
the:
Instructions 72. The physician documents the medications that the patient is to
take after discharge in the section of the discharge
summary.
TRUE 78. If a patient is admitted through the ED, the original ED record
is placed on the inpatient record. TRUE/FALSE
COBRA of 1986 80. Which law prevents hospitals from "dumping their indigent
patients on other institutions"?
Risk/benefits of transfer, 81. State one criterion that the physician documents in the
phone conversations re: emergency record about the transfer or the screening exam.
patient's condition, patient
request for transfer, patient's
condition upon transfer,
physician recommendation
for transfer